The Sorry State of Medical Research in India

The ICMR could not even list one practical application of its hundreds of research papers published in national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.ETHealthWorld | April 18, 2017, 18:01 IST

New Delhi: The Indian Council of Medical Research (ICMR), which has about 800 scientists working across 32 institutes in the country, cannot list even one new intervention -- in terms of new drug, vaccine, diagnostic test or treatment procedure -- developed by its hundreds of scientists over a period of last two years. The ICMR could not even list one practical application of its hundreds of research papers published in national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge. So, where did the sum of Rs 1558.89 crore spent between April 2015 and February 2017 by the Council went?

On being asked by the Parliamentary Standing Committee on Health and Family Welfare about the major achievements of ICMR during 2015-16 and 2016-17, the Department of Health Research, the parent body of ICMR, had the following to share:

Research Output during 2015

• ICMR scientists published total 965 papers during 2015. Thirty-three patents were filed and two patents were granted. Efforts were also made for transfer of technologies developed by ICMR to industry for commercialization. ICMR funded a total of 1745 research projects including fellowships during the year, while 292 new research projects including fellowships were approved.

Research Output during 2016

• New field station of NIRTH was established at Keylong in Lahaul and Spiti area of Himachal Pradesh to work on the health problems of the tribals. Satellite Centre of NIIH started functioning at Chandrapur, Maharashtra in the area of sickle cell anaemia G6PD.

• ICMR scientists published a total of 720 research papers in various national and international journals. A total of 12 patents were filed and 1 granted.

• ICMR institutes continued to provide training to various state level health officials and ICMR also continued to provide fellowships like JRF, SRF, RA and STS to encourage youngsters to pursue research career.

• MD/PhD programme is continuing in 3 universities. More than 500 Non-ICMR scientists were given financial assistance to attend conferences abroad.

Currently, health research in the country is primarily carried out by 31 institutes of ICMR which was established in 1911 and is one of the oldest medical research bodies in the world.

In the last two years i.e. 2015 and 2016, 1685 research papers (965 in 2015 and 720 in 2016) were published by the ICMR scientists and three patents were granted against 45 patents filed. Compare this with the research output of the All India Institute of Medical Sciences (AIIMS), New Delhi, which alone publishes more than 1,100 research papers in a year. And research is just one responsibility of the AIIMS, others being providing medical education and tertiary healthcare. The annual budget of the AIIMS was Rs 1820 crore (actual) and Rs 2293 crore (revised estimate) during the year 2015-16 and 2016-17 respectively.

Year-wise Actual Expenditure of Department of Health Research (including ICMR)

Financial Year

Actual Expenditure (Rs in crore)

% increase of expenditure over previous year

2012-13

461.84

2013-14

569.61

23.33%

2014-15

590.65

3.70%

2015-16

647.82

9.67%

*2016-17

911.07

40.66%

* Expenditure upto February, 2017

“This clearly indicates that the health research output (of ICMR) is not up to the mark and not commensurate with the magnitude and disease burden in India. Given the fact that the country contributes to a fifth of the world’s share of diseases (12th Plan Report) and one of the vital elements in improving this situation is the need for a relevant research base that would equip policy makers to take informed health policy decisions, the health research output needs to be augmented substantially to cater to the health challenges faced,” observed the Parliamentary Standing Committee on Health and Family Welfare in its 100th Report on Demands for Grants 2017-18 of the Department of Health Research. The Report was presented to Rajya Sabha on March 20 and laid on the table of Lok Sabha on the same date.

ICMR, funded by the Union Ministry of Health and Family Welfare, is an apex organisation to formulate, conduct, coordinate and promote biomedical research in India. It is one of the oldest medical research bodies in the world.

ICMR’s research priorities include control and management of communicable diseases, fertility control, maternal and child health, control of nutritional disorders, developing alternative strategies for healthcare delivery, containment within safety limits of environment and occupational health problems, research on major non-communicable diseases like cancer, cardiovascular diseases, blindness, diabetes and other metabolic and haematological disorders, mental health and drug research (including traditional remedies). All these efforts are aimed at reducing the total burden of disease and to promote health and well-being of the people.

Now did you find among the ICMR’s priorities a mention of publishing research papers? But apparently that seems to have the real focus of the scientists: a clear case of means justifying the ends!

So, why has the ICMR not been able to produce real research results that could match with its avowed priorities? There are, of course, usual suspects like inadequate funds and human resource.

The total Twelfth Plan outlay (2012-13 to 2016-17) earmarked for the Department of Health Research (including ICMR) was Rs 10,029.00 crore. Out of the total outlay, the BE (Budget Estimate) allocation from 2012-13 to 2016-17 was Rs 3,575.17 crore which was further reduced to Rs 3,266.50 crore (32% of the approved outlay) at the Revised Estimate (RE) stage. The actual expenditure was Rs 3,180.99 crore for the entire Twelfth Plan period (upto February 2017). So, there was a huge mismatch to the tune of Rs 6,762.50 crore between the Twelfth Plan Outlay and the RE allocation made for the Department.

The Parliamentary Committee, chaired by Prof Ram Gopal Yadav, observed that though it is always possible to generate more value for the funds allocated, it would be unrealistic to expect to achieve key goals of health research or to make spectacular break-through in the newly-emerging frontier areas of health research with only 32% of the approved outlays.

Year-wise Projected Demand and Actual Allocation of Department of Health Research (including ICMR)

Financial Year

Projected Demand (Rs in crore)

Actual Allocation (Rs in crore)

2013-14

2283

726

2014-15

2581.5

726

2015-16

2817.91

713.17

2016-17

1689.43

750

2017-18

2933

1500

In its report the Committee noted that “there is a huge, persistent and recurring mismatch between the projected demand for funds and actual allocation of the schemes/projects of the Department of Health Research”. For instance, the actual allocation for the department during 2015-16 was Rs 713.17 crore against the projected demand of Rs 2,817.91 crore. And though the actual allocation for the department has been more than doubled at Rs 1,500 crore for the year 2017-18, it’s still just about half of the projected demand of Rs 2,933 crore.

According to the Department of Health Research, inadequate budgetary allocations are likely to affect the research activities of the institutes of ICMR since after meeting the normal office expenses and funding of extra mural projects, hardly on an average Rs 50 crore are available to accommodate the requirements of providing consumables, chemicals and reagents across the 32 institutes and other laboratories/field stations.

Dr Soumya Swaminathan, Secretary, Department of Health Research and Director General, Indian Council of Medical Research (ICMR), pointed out to the Committee that the budget of National Institute of Health in the US (a body whose mandate is similar to that of ICMR) is 32 billion dollars a year, and a large amount of that budget goes into basic research. In comparison, the budget of ICMR for the current year (2017-18) is equivalent of a mere $232 million. Notably, ICMR spent an equivalent amount during the previous two years. Dr Swaminathan further informed that it takes two-and-a-half billion dollars to develop a new drug from scratch and it needs thousands of scientists working on it at different stages. So, that explains to some extent why the research output of ICMR leaves much to be desired.

Dr Swaminathan told the Committee that the Department would try to maximise the output with the given allocation of Rs 1500 crore in the year 2017-18. “Small amount of money would be distributed to many small projects across the country and hence a very big impact in health research may not be seen. Therefore, certain themes have been selected for the next 4-5 years including TB, MDR TB, drug resistance, viral infections, other vector borne diseases and other non-communicable diseases.”

The Committee observed that if the objective of providing affordable quality healthcare for the people and translating research outputs into measurable social and national outcome is to be realised, investments in health research will have to be increased substantially.

But the lack of adequate funding and manpower are just some of the reasons behind the sorry state of medical research in India. Another major reason for this is under-utilisation of allocated funds. For instance, allocation for the Network of Laboratories for Managing Epidemics & Natural Calamities for the year 2016-17 was Rs 41.50 crore but only Rs 37.72 crore could be utilised till February 2017. Again, out of Rs 14.25 crore allocated for grants-in-aid, only Rs 10.04 crore had been utilised. Similarly, the fund utilisation for international cooperation was only Rs 0.28 crore out of Rs 1.00 crore allocated for the purpose during the year.

Yet another reason why health research in India is hamstrung is the paucity of relevant data. Even Dr Swaminathan admitted before the Committee that “we need large population based surveys” to do meaningful research.

ICMR’s intramural research (research conducted by its own institutes) is carried out through a countrywide network of 31 institutes or centres, out of which 17 deal with communicable diseases; 6 with non-communicable diseases; 2 deal with diseases related to reproductive and child health (RCH); 3 deal with nutritional deficiencies; and 3 deal with disease related to basic medical sciences including haemoglobinopathies and traditional medicine. Extramural research is promoted by ICMR through-setting up Centres for Advanced Research in different research areas around existing expertise and infrastructure in selected departments of medical colleges, universities and other non-ICMR research institutes.

A major part of ICMR’s extramural research activities are conducted in government medical colleges where research is a mandate of postgraduate training in both the MCI (Medical Council of India) and the NBE (National Board of Examinations) programmes. The country produces around 30,000 postgraduate students every year who are required to complete a research thesis for a degree. “But due to multiple reasons, like inconsequential research topics, inappropriate research mythologies, poor guidance etc, potential scientific talent of PG students is wasted. If postgraduate students could be guided to conduct research relevant to the national health system, critical human resource gaps can be filled,” observed the Committee, adding, it “would therefore, like the ICMR to guide postgraduate (medical) students in their dissertations by linking with them and faculty guides across India.”

It’s not like that ICMR doesn’t have something substantial to show as its achievement. For instance, ICMR has come up with a micronutrient (fortified food to fight malnutrition). The National Institute of Nutrition (NIN), Hyderabad has developed several food fortification intervention programmes like Iron Fortified Salt (IFS) and Double Fortified Salt (DFS), which is fortified with both iron and iodine to combat iron and iodine deficiency in the country. NIN Hyderabad has also developed multiple micronutrient powder (MNP) and supplemented the same to children of 6 months to 48 months in Nalgonda district of Telangana in cluster randomized trial and used at point of care. The intervention with multiple micronutrient trial has shown a significant improvement in Hb (haemoglobin), iron, zinc, folate and vitamin 12 and child development indicators like cognition, motor, social, and emotional development were also improved after one year of its continuous and regular implementation. After successful trials, the MNP is now being manufactured by MS Primal Healthcare, Mumbai and is ready for use in any intervention programme.

The Committee believes that with the intervention of multiple micronutrients amongst children for eliminating malnutrition, a major problem of the country could be solved. The World Bank estimates that India is one of the highest ranking countries in the world in respect of the number of children suffering from malnutrition. The 2015 Global Hunger Index Report ranked India 20th amongst leading countries with a serious hunger situation. India’s National Family Health Survey (NFHS) and State Government’s School Health Programme (SHP) have also indicated that the number of anaemic and malnourished children is rising. As per the latest SHP report for the year2015-16, the number of anaemic children is 6.06 lakh that increased from 5.13 lakh in 2014-15.

To deal with the menace of the growing antibiotic resistance, ICMR has issued guidelines to 20 hospitals giving them directions on antibiotic use, dosage and duration of treatment. This has been done to bring about a change in the way antibiotics are prescribed. Antibiotic resistance is one of the biggest threats to our health. It can affect anyone and generally occurs due to misuse of antibiotics. A growing number of infections such as pneumonia, tuberculosis, gonorrhoea etc are becoming hard to beat as the antibiotics used to treat them have become less effective owing to their persistent misuse. The issue was recently flagged by the World Health Organisation (WHO) which cited presence of severe super bugs which are difficult to treat with the present knowhow in the field of antibiotics. These superbugs are seen as a growing threat to modern medicine. India is one of the world’s biggest consumers of antibiotics. In India, antibiotic resistant neonatal infections claim lives of 60,000 newborn babies each year, according to the review on Antimicrobial Resistance paper published in 2016.

After going through the 32-page report of the Parliamentary Standing Committee, the impression one gets is the Department of Health Research and its flagship organisation ICMR have been making lots of efforts like setting up research institutions, giving grants for extramural research, publishing research papers, sponsoring foreign travel of Indian researchers to attend international conferences, entering into research partnership with other countries and organisations etc. But what is missing is any specific mention of a particular medical research and its actual application which has helped ameliorate a disease or made its diagnosis or treatment more accurate or effective. Though the Report talks about three patents granted to the ICMR in the last two years, there is no mention of the exact research findings for which the patents were granted and how these patents are going to help the people of this country. (An email sent to the ICMR Director General to get information on this could not solicit response by the time of filing this article.)

Research for the sake of it can hardly make any difference in the country’s disease burden or make the life of its people any better or their pain due to various diseases any lesser. Perhaps, it’s time for a deep review of not just the efforts but the exact outcome of the premier research body.

Commenting on the current state of medical research in India, Dr Kamal Mahawar, a Consultant General and Bariatric Surgeon with Sunderland Royal Hospital & an Associate Clinical Lecturer with Newcastle University in the United Kingdom (UK) and the author of ‘The Ethical Doctor’, told ETHealthWorld:

“Research is indeed a key area of deficiency in our society - and not just in medicine. The problem is that research needs top professionals and these professionals are not cheap. We have to start paying wages similar to Western universities, if not more (to compensate for a lower quality of living etc) to attract top academics. There are plenty of top academics of Indian origin in the world, who will relocate for the right freedom and pay!

“In India, academic positions are largely given out in a time bound fashion irrespective of any real output or any real contribution. In the west, you only become a professor if you have made some real contribution. If everybody is going to become a professor anyway, what is the incentive in carrying out research?

“Research needs infrastructure and that needs money. In Western societies, this money comes from three sources -- government, charities and NGOs, and universities. Our government places low priority on research. Charities are busy promoting the cause of god! And universities are underfunded and don’t have any autonomy to raise funds through either increasing the fees for students or other means.”